Health care regulatory services

Participation in the Medicare program, either as a health care provider or a health plan, presents both risks and opportunities to organizations. As the number of Medicare beneficiaries is expected to increase over the next decade, regulators are expected to continue to take a prominent role in shaping health care in the US. Deloitte’s Health Care Regulatory Support teams with health plans, health care providers, pharmacies and pharmacy benefit managers, and other organizations across the care continuum to help address emerging guidance and assist organizations with maintaining compliance with existing rules governing the Medicare Program.

The Medicaid program has experienced evolutionary change over the past decade of its existence. Given the expected increase in Medicaid enrollment predicted as a result of the current financial situation brought about by COVID-19, change is expected to continue. With change comes challenges to both health plans and health care providers. For plans, stringent contract requirements make operational and compliance excellence paramount. For providers, the diminished levels of reimbursement provided for Medicaid patients compel value-based portfolio strategies. As change continues, organizations will likely continue to contend with these challenges.

Pharmacy services go beyond just getting your prescriptions filled. Pharmacies work in close coordination with health care providers, health plans, pharmaceutical companies, group purchasing organizations (GPO), wholesalers, and other pharmacies to provide their communities with seamless and timely access to medications. Additionally, the traditional role of the pharmacist continues to evolve particularly as there is an increase in:

• The role pharmacists play in clinical decision-making

• The use of automation and technological advancements

• High-cost specialty medications with plan-imposed restrictions and guardrails

As the roles of pharmacy and the pharmacist continue to evolve, it’s vital that organizations are well-informed and have adequate controls in place to comply with guidelines and rules from the multiple regulatory and other governing parties that oversee pharmacy operations. These controls help protect organizations against vulnerable areas ripe for noncompliance, including billing operations, documentation management, and controlled substance practices. Deloitte works with pharmacies and related entities across the end-to-end continuum of care to help them understand emerging guidance, assist organizations with maintaining compliance with existing governing rules, and find new sources of value to drive efficiency and growth in a competitive market.

The past decade has seen a convergence of regulatory disruption and macro technology forces. Emerging federal requirements have the potential to be a key catalyst to ignite multiple changes in the health industry that promote higher-quality, lower-cost care. As regulators increasingly focus on giving patients agency over their health care journey, Deloitte’s Health Care Regulatory Support team is assisting clients to capitalize on these opportunities in a way that aligns with and expands upon evolving federal requirements to create strategic differentiation.